Personal Care: Should Personal Assistants be Regulated by CQC?
Personal Care includes supporting people with washing, showering and personal hygiene and this is regulated by the Care Quality Commission. This type of care is often provided to people at home by domiciliary or home care providers but can also be provided by private carers known as personal assistants who are self-employed or employed directly by the person receiving care.
Care in your own home is means tested which means some people pay for all their support while others may have their support funded either fully or in part by their local authority. Most home care services are delivered by providers registered with the Care Quality Commission (CQC) and commissioned by local authorities. However, local authorities can also provide people with their own personal budget to make their own care arrangements by privately employing a personal assistant. As they are employed directly by individuals they are not required to register with CQC and therefore do not receive any monitoring or inspection of their services. They are encouraged by local authorities to seek training and to obtain a DBS check and people employing them are encouraged to create a job description, provide an employment contract and seek background checks.
Healthwatch Report on Non-regulated Services
In 2015 Healthwatch [Ref 1] wrote to the Department of Health outlining their concerns about the safety of people receiving health and care services by services or individuals who are not currently regulated by CQC. The Department of Health responded by citing the responsibilities of local authorities to “regularly review care provided by personal assistants and follow safeguarding principles to ensure the person is not at risk of abuse or neglect”.
When the Care Act came into force in April 2015 this placed a legal duty on local authorities in England to arrange services that promote independence for disabled people. Local authorities became legally obliged to offer anyone eligible for care a personal budget. This budget can be used to employ a personal assistant to provide personal care and other services in people’s own homes.
Duty of Care
Personal assistants have a duty of care to their clients and must report any safeguarding concerns to the local authority. However, no formal system is in place to ensure they receive appropriate training so they know what a safeguarding concern is and how to report it. Additionally, the people receiving support may also lack understanding in this area and be unaware of the need to report issues they have experienced with their personal assistants.
Research from Cambridge University [Ref 2] which aimed to investigate whether personal budgets increase the risk of abuse found that “the main perpetrators of alleged abuse to be home-care employees”. However the research does not take into account that personal assistants are not monitored for quality or safety and do not need to undertake safeguarding training. It does not consider that home care providers are highly monitored and regulated and therefore instances of providers themselves or others reporting safeguarding incidents will be higher.
Safeguarding People from Abuse
Home care providers must adhere to the Care Quality Commission's regulation 13, Safeguarding service users from abuse and improper treatment and are legally bound to report and act upon safeguarding issues and must adhere to a further 24 regulations which support safe and effective care.
Non-regulation of personal care can create a potential for abuse and exploitation as described in the scenario below:
A carer supports an older lady at home to get washed and dressed. The carer starts to make inappropriate comments towards her. The comments make the person feel uncomfortable and after a while she talks to her daughter about it.
What could happen when employing a personal assistant:
The daughter decides to let the carer go and employ a different carer. Her Mum is embarrassed by the situation and doesn't want a fuss made. The carer finds other work caring for a disabled or older person in their home. The daughter is unaware of the potential safeguarding issue and the carer is unlikely to seek further training or report herself.
What happens when receiving care through a registered care agency:
The daughter reports this to the care manager and the carer is suspended while an investigation takes place. The manager informs the local authority, the safeguarding board and the Care Quality Commission. An investigation takes place and details are discussed within a safeguarding meeting. The care provider instigates further training and improvements as a result of the concern and may take disciplinary action against the carer.
This does not mean that all personal assistants are likely to exploit vulnerable people but it highlights the issue of how non-regulation of care services creates a risk to care recipients and how safeguarding could be significantly underreported in this area.
The Rise of the Micro Provider
The estimated total workforce of personal assistants has continued to grow since the introduction of the Care Act and is now estimated to include over 100,00 people Front Public Health Journal, National Library of Medicine [Ref 3]. Along with this growth in personal assistants, there has been a move by local authorities towards supporting smaller community-based care enterprises, who, due to a loophole in CQC regulations, do not always have to be registered. These organisations are often referred to as “Micro Providers” and offer a range of services in people’s homes including personal care. They are supported to set up small care enterprises in their local community by organisations such as Community Catalysts CIC.
To become a micro provider under this scheme, applicants need only sign up to the 8 page document, “Doing it Right” quality standards [Ref 4]. Community Catalysts run a development programme for people interested in starting their own social care enterprise and help local authorities make changes to how they commission care in order for them to utilise the social enterprises or micro providers in their county.
Community Catalysts do not have to register with the Care Quality Commission as their role does not include employing or monitoring the care services of personal assistants. They cannot gather feedback about the care delivered or advise personal assistants about how to carry out personal care. Somerset local authority in partnership with Community Catalysts CIC has been supporting the development of micro providers since 2015 and they now provide 31,122 hours per week to 5,903 people in Somerset.
In 2017 the Social Care Institute for Excellence published a report [Ref 5] by Community Catalysts CIC on the impact of community micro providers in Somerset. Their evaluation of the project stated “micro providers deliver strong and valued outcomes for the people they support and significantly outperform traditional domiciliary care delivery”. However the report was only based on a survey of 45 families who had experience of both micro providers and home care providers and since Community Catalysts are not registered with CQC they are unable to gather feedback about the quality of the care delivered on a daily basis.
More local authorities across the country are now supporting the development of these small enterprises by working in partnership with and commissioning services from the Community Catalysts CIC.
Community Catalysts say that “homecare doesn’t always care” and that poor terms & conditions within the sector mean people can’t get the care they need. A narrative that tends to blame the home care sector for the current issues of recruitment & retention caused by chronic government underfunding over the past ten years.
Homecare Deficit Report
The issues within the home care sector are highlighted in the Homecare Associations Homecare Deficit report [Ref 6] 2021 and include poor pay, terms and conditions, and carers feeling undervalued compared with equivalent roles in the NHS. Local authorities pay private home care providers an hourly rate to deliver personal care in people’s homes which means that although these providers are private businesses they are only able to provide good pay, terms and conditions if the council provides an adequate hourly rate.
Although local authorities are inundated with requests for support at home and NHS trusts are unable to discharge people from hospital, only 1 in 8 local authorities were paying the Homecare Associations minimum price for homecare of £21.43 per hour in 2021. This is the minimum price that the association says is needed to ensure providers can comply with the national minimum wage and care regulations. The report goes on to say, “low fee rates for homecare are a direct consequence of inadequate central government funding for social care. In turn, this leads to poor pay, terms and conditions for the workforce”. This situation has led to people being unable to access care at home and hospitals being unable to discharge people.
Unmet Care Needs
An article published in September 2022 by Homecare Insight [Ref 7] highlighted the results from the Age UK and Care and Support Alliance study which found that 2.6 million people aged over 50 are now living with some form of unmet care need in England. This includes people not being able to independently go to the toilet, get out of bed or wash themselves properly.
With limited financial resources from central government, local authorities must find a way to increase care capacity in order to reduce the unmet need within their authority areas. Encouraging micro providers and personal assistants to provide personal care certainly saves money. According to the Community Catalysts report [Ref 5] on the impact of their scheme in Somerset, it has delivered an annual saving of £936,607 for Somerset County Council.
Deepening the Crisis in Recruitment and Retention
For people that want the option of employing their own personal assistant, companies like, Community Catalysts help to provide this opportunity within local communities. Local authorities benefit as they are able to fulfill the requirements of the Care Act 2014 by supplying opportunities for people to use their own personal budgets and make savings on care costs. Unfortunately, there is a negative effect on CQC registered home care providers who lose their trained and vetted staff to these new schemes when recruitment and retention is already in an absolute crisis across the sector. Whilst personal assistants are no doubt a fantastic option for some people they remain unregulated and there are risks associated with only having a limited pool of carers available to provide care. People using a personal budget have the option of either hiring a self-employed or an employed personal assistant.
The self-employed personal assistant does not require a contract and this can leave people in a situation where care cover isn't available to them if the personal assistant is unwell or has to take a break from their role. People can also directly employ their own personal assistants but this means they become an employer with extensive responsibilities including working out their pay & pension contributions, ensuring they receive statutory holidays and maintaining their employee's health & safety whilst at work.
People are living longer and the demand for personal care services at home continues to grow each year with many people having multiple long-term conditions. Flexible and innovative options are needed and welcomed but regulation should be across the board. People have the right to a well trained closely monitored team of professionals to give them the consistency, high quality and reliable service they deserve.